Ministry of Consumer Affairs

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posted:: 9/17/2012
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Nominations Service – Application Form

Instructions
If you wish to apply to join the database of Ministry of Consumer Affairs
Consumer Representative Nominations Service, please complete all sections
of this form and either

Post it to:
Consumer Representative Nominations Service
Ministry of Consumer Affairs
P O Box 1473
Wellington.

Email it as an attachment to: consumerrep@mca.govt.nz

Fax it to: 04 472 9400

Deliver it to:
Ministry of Consumer Affairs
Ministry of Economic Development Building
33 Bowen Street
Wellington 6140

Please Note
If your application is successful, you will be advised in writing and asked to
provide an up to date CV. However the Ministry of Consumer Affairs (MCA) is
under no obligation to find you a position and there can be no guarantee that
a paid or unpaid offer of appointment will be made to you.

For a variety of reasons, including meeting the needs for qualifications and
diversity, not all applications to join the database of Ministry of Consumer
Affairs Consumer Representative Nominations Service will be accepted.

If your application is unsuccessful, you will be advised in writing and you may
be encouraged to re-apply at a later date.

Application form for MCA Consumer Representative Nominations Service 1
730941
Use of your information
Should your application be accepted, the Ministry of Consumer Affairs (MCA)
will use the information to match your skills and experiences against available
positions as consumer representatives on advisory boards, committees and
state sector boards.
The information you provide will be held by MCA, and may be disclosed, for
the purpose of determining your suitability for any position, to:
 Ministers of the Crown, their offices, and Members of Parliament when
candidates are being considered for appointments
 Government agencies involved in nominating, appointing or supporting
individuals on state sector boards and committees

 Other appointing agencies.

By submitting your application, you are agreeing that MCA may collect
information about you from people and organisations named in the
application and who can verify the information that you have included.

You do not have to provide the information that we request. However, if you
do not do so MCA may be unable to consider your application.

Under the Privacy Act you are entitled to request access to, and correction of,
any personal information that MCA holds about you. If you wish to do so, or if
you have any questions or concerns about how your personal information
may be collected, used or stored by MCA, please feel free to contact us on 04
474 2692 or at our address listed above.

By submitting your completed application, you agree to the above conditions.

Signature: Date:

If you are sending this form electronically, please type your name and date in
the signature and date fields above.

Application form for MCA Consumer Representative Nominations Service 2
730941
Ministry of Consumer Affairs Nominations Service
Application Form
Note: The questions that are marked by a star (*) must be completed.

Personal details
Title (Mr/Mrs/Miss/Ms/Dr)
Surname *
First name *
Date of birth
Gender *
Citizenship status *
(NZ citizen, NZ resident)
Other citizenships
Ethnicity
Which ethnic group do you belong to? Mark the space(s) that apply to you.
NZ European
Maori
Samoan
Cook Island Maori
Tongan
Niuean
Chinese
Indian
Other (such as Dutch, Japanese,
Tokelauan) Please state

If Maori, please state iwi and hapu affiliations
Iwi affiliations
Hapu affiliations

Application form for MCA Consumer Representative Nominations Service 3
730941
Home address
Address *
Suburb
Town
Local authority *
(Please indicate your local
authority from the list on the
next page)
Post code

Postal address
(If your postal address is different from your home address above, please tell us)
Address 1*
Suburb
Town
Post code

Contact details
(Please provide at least one phone number, including area code)
Work phone
Work fax
Home phone
Home fax
Mobile phone
Email
What is the best way
to contact you during
the day? *

Application form for MCA Consumer Representative Nominations Service 4
730941
List of Local Authorities
1. Ashburton District Council 38. Otorohanga District Council
2. Auckland City Council 39. Palmerston North City Council
3. Buller District Council 40. Papakura District Council
4. Carterton District Council 41. Porirua City Council
5. Central Hawke's Bay District Council 42. Queenstown-Lakes District Council
6. Central Otago District Council 43. Rangitikei District Council
7. Chatham Islands Council 44. Rodney District Council
8. Christchurch City Council 45. Rotorua District Council
9. Clutha District Council 46. Ruapehu District Council
10. Dunedin City Council 47. Selwyn District Council
11. Far North District Council 48. South Taranaki District Council
12. Franklin District Council 49. South Wairarapa District Council
13. Gisborne District Council 50. South Waikato District Council
14. Gore District Council 51. Southland District Council
15. Grey District Council 52. Stratford District Council
16. Hamilton City Council 53. Tararua District Council
17. Hastings District Council 54. Tasman District Council
18. Hauraki District Council 55. Taupo District Council
19. Horowhenua District Council 56. Tauranga City Council
20. Hurunui District Council 57. Thames-Coromandel District Council
21. Hutt City Council 58. Timaru District Council
22. Invercargill City Council 59. Upper Hutt City Council
23. Kaikoura District Council 60. Waikato District Council
24. Kaipara District Council 61. Waimakariri District Council
25. Kapiti Coast District Council 62. Waimate District Council
26. Kawerau District Council 63. Waipa District Council
27. Mackenzie District Council 64. Wairoa District Council
28. Manawatu District Council 65. Waitakere City Council
29. Manukau City Council 66. Waitaki District Council
30. Marlborough District Council 67. Waitomo District Council
31. Masterton District Council 68. Wanganui District Council
32. Matamata-Piako District Council 69. Wellington City Council
33. Napier City Council 70. Western Bay of Plenty District
34. Nelson City Council 71. Westland District Council
35. New Plymouth District Council 72. Whakatane District Council
36. North Shore City Council 73. Whangarei District Council
37. Opotiki District Council

Application form for MCA Consumer Representative Nominations Service 5
730941
Consumer representation experiences
Please provide details of positions you have held on a board or committee as
a consumer representative. Start with the most recent position. Please also
indicate whether you were elected or appointed. If you have had more than
five, please list the rest at the end of the table.

We may contact any or all of the listed organisations to verify the information
you provide.

In the “Type” question, you should use one of the following categories:
Crown, Incorporated Society, Company, Trust, Community organisation or
Other.

A board or committee member in each of these types has a slightly different
role and different responsibilities, so it is useful for us to know which one you
had.

Type Organisation Position title and brief Elected or Start/finish
description appointed dates

If you have had more than five positions, please list them here:

Application form for MCA Consumer Representative Nominations Service 6
730941
Governance experiences
Please provide details of any governance positions that you have held. Start
with the most recent position. If you have had more than five, please list the
rest at the end of the table.

In the “Type” question, you should use one of the following categories:
Crown, Incorporated Society, Company, Trust or Community organisation.

A board member in each of these types has a slightly different role and
different responsibilities, so it is useful for us to know which one you had.

Type Organisation Position title Elected or Start/finish
appointed dates

If you have had more than five positions, please list them here:

Application form for MCA Consumer Representative Nominations Service 7
730941
Supporting information
The following information will help us when we are looking for nominees for
boards with specific requirements, and for matching the best person to a
position.

Consumer constituency
Please describe the consumer constituency(s) and/or community(s) you can
best represent. Eg: parents, people on low incomes, senior citizens, gay
people, new migrants, rural consumers.

Community experience (unpaid)
Please provide details of up to five community projects or organisations you
have been or are involved in.

Name of project or Your role Start/finish Brief description
organisation dates

Application form for MCA Consumer Representative Nominations Service 8
730941
Work experiences (paid)
Please provide details of up to five jobs that you have held, part-time or full-
time including self employment. In the “Sector type” question, use one of the
following categories: Government, Business or Community.

Sector type Name of project or Your title Start/finish Brief description
organisation dates

Educational, trade and professional qualifications

Highest educational qualification/s:

Trade and/or professional qualification/s:

Any other area/s of expertise (including language and cultural
knowledge/experience):

Application form for MCA Consumer Representative Nominations Service 9
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Skills
Please indicate which of the following skills you could bring to a board, to
assist them in their work (delete the skills that are not applicable to you).
Communications Governance
Legal Finance
Leadership Management
Business Consumer perspective
Disability perspective Community perspective

Other (please tell us):

Industries that you have had experience in
Please use the following list of industries to indicate the areas you have
experience and knowledge of, worked in, or been involved with.

Industry experience

List of Industries
A. Agriculture, Forestry and Fishing K. Financial and Insurance Services
B. Mining L. Rental, Hiring and Real Estate
Services
C. Manufacturing M. Professional, Scientific and
Technical Services
D. Electricity, Gas, Water and Waste N. Administrative and Support
Services Services
E. Construction O. Public Administration and Safety
F. Wholesale Trade P. Education and Training
G. Retail Trade Q. Health Care and Social Assistance
H. Accommodation and Food Services R. Arts and Recreation Services
I. Transport, Postal and Warehousing S. Other Services
J. Information Media and
Telecommunications

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Awards
Please provide details of any award you have received. An award can
acknowledge expertise, involvement and contributions to your community,
which can be used to support a nomination.

Award Organisation giving the award Year

Summary
Please tell us why you would like MCA to nominate you as a consumer
representative on a board, committee or agency.

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Referee information
Please provide details of two referees who can vouch for you as a consumer
representative. We will contact your referees to verify the information you
have given us.
Name *
What is your relationship to this
referee? *
Please provide at least one phone number where we can contact your referee
between 9 am - 5 pm, Monday to Friday.
Phone Fax
Cell phone Email

Postal Address *
Address
Suburb
Town
Post Code

Name *
What is your relationship to this
referee? *
Please provide at least one phone number where we can contact your referee
between 9 am - 5 pm, Monday to Friday.
Phone Fax
Cell phone Email

Postal Address*
Address
Suburb
Town
Post Code

Application form for MCA Consumer Representative Nominations Service 12
730941